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Appllic S IIS yc*si n Itted Properly Completed. Be Sure To Sign The Application. FOR 'iFFICE LIVE: PPLICATION Anticipated Completion Date: ' }y { r on- I I terable, Revocable, Suspendable) July 12th, 1981 YYdlMAY 13 9 �IRONMENTAL HEALTH PERMIT �p&WELD (COMPLETE IN TRIPLICATE) SAID .f+. in,�j!NiAin;-AL WATER QUALITY Application is hereby made to the S Aiq- iHLd@4I"gk!h-Etstrictforapermittoconstructand/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 6808 Haight Rd, City/Town i Owner's Name Bob Dutcher Phone Address 3603 Cumberland Ct. City Stockton Q Contractor's Name Goehring Pump & I rrigati011icense# 309031 Business Phone 727--5548 Contractor's Address 17754 N. Hwy. 88., Lkf d. Emergency Phone + Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes XX No y T�YPEOF WORK (CHECK): NEW WELLDEEPEN ❑ RECONDITION E] DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 12-�.-,.PUMP. I.NSTALLATIONO2 PUMP REPAIR 1111 ,, I! REPLACEMENT❑ ,.�.,.-.,......:.._�_-.. i DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other PropertyLine= -—Private Domestic Well_. - - Public Domestic Well INTENDED USE TYPE OF WELL �x _ �.. ❑ INDUSTRIAL ( � GABLE TOOL �`' Dia of Well Excavation MESTIC/PRIVATE T' 11 DRILLED Dia, of Well Casing - ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing. r ❑ IRRIGATION _ ❑ 'GRAVEL PACK { Depth of Grout Seal ❑ CATHODIC PROTECTION J.7 ❑ ROTARY �' Type of Grout ❑ DISPOSAL f ❑ OTHER "Other Information _. M�-^- ❑ �, �.,� Surface Seal,Installed.By:_ - PUMP INSTALLATION: Contractor" "-Goe tri Pump & -,Irrigation; T..: -Type of PumpSLi}JTCIerSlblEy _... _ . z. PUMfs R PL-ACEMIENT f ❑ State Work Done PUMP REPAIR: 0 State Work Done DESTRUCTION OF WELL: ' Well Diameter Approximate Depth :- "-Describe-Material and Procedure.- -. ---- - --.-- ----- f I hereby certify fhat I have prepared this application and that the work wi)J..be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:"I certify that in the performance 6f•the work iorwhich this permit 1 is issued, I shall hot employ any person in such manner as•to become subject to workman's-compensation laws of California." r Contractor's hi ri or sub-contracting.signature certifies the following:"I certify that in the performance of the work for which this permit =shall employ persons subject to workman's compensation laws of California." ,'- I will r Inspection prior to�grouting-and•`a final inspection. j Signed X I Title: Bkpr. I Date: 05/13/81 t (Draw Plot Plan on Reverse Side) ' _#,_ t FOR DEPARTMENT USE ONLY PHASE I 0 Application Accepted By Date J Additional Comments: Pha a II Grout Inspection ase.111 i 1 Inspection Inspection By� I Date Inspection By ate t Fee IS Due: ❑ ANNUALLY ❑ PEA UNIT El SITE ❑ EACH El January 1 &Received By January 31 El July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED / AMOUNT FEE LESS PRORATION ;{ ' PLUS i PENALTY 1 OTHER OTHER . r y Received ly Date Receipt No Permit No. Issuance DateMailetl Delivered e k APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH-PERMITISERVICES 'n 1601'E.HAZELTON AVE.;P.O.Boz 2009 STOCt(TON,CA 95201 'i